Posts Tagged ‘Health Affairs’


When Metrics and Testing Replace Listening and Physical Assessment

June 13, 2014

By Gail M. Pfeifer, MA, RN, AJN news director

Emergency x 2 by Ian Muttoo, via Flickr.

by Ian Muttoo/via Flickr

I was appalled as I read the Narrative Matters column by physician Charlotte Yeh in the June issue of Health Affairs, for two reasons. Aside from the compassion I felt for her suffering at being hit by a car on a rainy Washington, D.C., evening in 2011, I was dismayed that most of her story took place in an ED, one of the settings in which I used to work. While there, she met with a series of omissions that included not just medical care omissions but also—though she never explicitly connects the dots—basic and serious nursing care omissions.

It saddens me to think that one of the things I fought so hard to implement on our unit more than 20 years ago—transforming the staff’s automatic labeling of arriving patients (an MI, an MVA, a gunshot wound) into a unique picture of who that patient really was under those traumatic circumstances—has still not come to pass. Yet that change of vision is so important to completing the picture and arriving at an accurate diagnosis. Noting that her care demanded a better balance of necessary test-based care and “an understanding of me as a person and what mattered to me,” Yeh points out how, for many providers, the clinical measures “can become more important than the patient.”

She narrates her view from the hallway stretcher as the ED team looks at cursory objective data only—some negative test results, the fact that she was not lying in the street when EMTs arrived (she had been moved by bystanders at her request, to avoid being run over by oncoming traffic), and that meds relieved her pain. But the objective signs that could have been gotten only from listening to her and from a solid nursing assessment were ignored for far too long.

I would expect a Level 1 trauma center team to know that clinical measures form only the tentative outline of a complete patient picture. Yet Yeh did not even receive a thorough history and physical from any member of the team. Yeh is a physician and understandably focuses her finger-pointing on medical care, which failed to order the tests that might have clarified the outline of what was happening with this particular “auto-ped.” Read the rest of this entry ?


‘Patient Activation’: Real Paradigm Shift or Updated Jargon?

February 7, 2013

By Jacob Molyneux, AJN senior editor

I attended a Health Affairs briefing yesterday in Washington, DC. Based on the February issue of the journal, it was called “A New Era of Patient Engagement.” A lot of research money appears to have been flowing to this area in recent years.

Our January article on "Navigating the PSA Screening Dilemma" includes a discussion of 'shared decision making'

Our January article on “Navigating the PSA Screening Dilemma” includes a discussion of ‘shared decision making’

The basic idea isn’t entirely new to anyone who’s been hearing the term “patient-centered care” for a long time: as Susan Dentzer writes in “Rx for the ‘Blockbuster Drug’ of Patient Engagement,” a useful article summarizing the main ideas raised in the Health Affairs issue: “Wherever engagement takes place, the emerging evidence is that patients who are actively involved in their health and health care achieve better health outcomes, and have lower health costs, than those who aren’t.”

One might add to these projected benefits: better experiences as patients.

Something’s got to change, so why not this? If many nurses feel they’ve heard all this before, the sense of a health care system in necessary flux is particularly acute right now, with mounting pressures from an aging Baby Boom generation with its full complement of chronic conditions, not to mention federal budget constraints and the influx of patients expected from the Affordable Care Act. It’s unlikely we’d be talking so much about patient engagement if we weren’t facing, perhaps as never before, the need to do something about the glaring gap between costs and quality in the U.S. health care system.

Patient activation. A term that got a huge amount of use at the briefing was “patient activation.” Hibbard and colleagues define it thus, in an article on the the evidence for cost reductions associated with patient activation: “understanding one’s own role in the care process and having the knowledge, skills, and confidence to take on that role.” Some examples of patient activation they cite are patients with type 2 diabetes performing regular foot checks and keeping a glucose diary, or patients who regularly exercise and get relevant screenings.

Don’t write off certain type of patients. Many of the presenters emphasized that it’s important to see patient activation as a possibility for every patient, whatever their socioeconomic level, disease severity, or cognitive limitations. As Hibbard put it, “there are more or less activated patients in every demographic.” Providers need to meet patients where they are and, as Marion Danis put it in an article on the ethical justification for getting patient activation right, set goals and have realistic expectations.

The physician problem. Many presenters noted that, without support from the health care system, individual efforts may not make much of a difference. In addition, physician resistance was mentioned repeatedly, whether attributed to their lack of time, their skepticism, or the overly common belief that more expensive care is always better. Bernabeo and colleagues observed that even those physicians who advocate shared decision making may not always engage in it. Their article on necessary competencies posits four crucial elements for true patient engagement: system support, providing patients with decision aids, collaborations and teamwork (can anyone say nurses?), and new reimbursement models.

Lin and colleagues, in looking at efforts to distribute decision aids in primary care practices, also noted physician-based problems with furthering patient activation, discovering that physicians

  • didn’t see a role for patients in their own care.
  • believed they lacked the time to give them decision aids.
  • didn’t see a potential benefit in doing so.

They also found, again unsurprisingly, that clinical support staff embraced the concept far more than the physicians did. Read the rest of this entry ?


What’s So Hard to Understand: Patient Safety, Quality Care Linked to Nurse Staffing

January 29, 2013

By Maureen Shawn Kennedy, AJN editor-in-chief

shawnkennedyThe data linking nurse staffing as well as shift length with patient outcomes and satisfaction with care continue to roll in. The latest report on nurse staffing, published in the January 13 issue of Medical Care by McHugh and MA, links higher nurse–patient ratios and good work environments to reduced 30-day readmission rates. Read the abstract here.

Most nurses seem to support better nurse–patient ratios, but there’s continuing ambivalence about reducing shift length, as seen in the comments we received on a recent blog post asking whether it’s time to retire the 12-hour nursing shift.

In August, researchers reported a link between nurse staffing and hospital-acquired infections.  Publishing in the American Journal of Infection Control, the authors noted a “significant association” between nurse–patient staffing ratios and both urinary tract infections and surgical site infections. Further, they noted that reducing nurse burnout was associated with fewer infections. (Read our news report on the study here.)

Health Affairs published a report in November called “The Longer the Shifts for Hospital Nurses, The Higher the Levels of Burnout and Patient Dissatisfaction.” The findings were there, loud and clear—researchers Stimpfel, Sloane, and Aiken found that “extended shifts undermine nurses’ well-being, may result in expensive turnover and can negatively affect patient care.”

And in December, we published a CE article (“Staffing Matters—Every Shift”) that looked at data suggesting that not just nurse–patient ratios, but the skill mix and relative experience levels among nurses in a unit, affected patient outcomes. (Here’s the blog post we ran describing the article’s main points.)

But all this shouldn’t be news. In 2004, Health Affairs carried a report by Ann Rogers and colleagues noting the link between long working hours and the risk of error. And in 2002, researchers led by Jack Needleman and Peter Buerhaus reported study findings in the New England Journal of Medicine: in brief, data from 799 hospitals in 11 states showed that more care by RNs (as opposed to LPNs or nurse aides) led to better patient outcomes. Read the rest of this entry ?


More Evidence: Should We Get Rid of 12-Hour Nursing Shifts, Despite Their Popularity?

November 27, 2012

By Shawn Kennedy, AJN editor-in-chief

A new study in Health Affairs provides yet more support that reliance on 12-hour nursing shifts (or longer—we all know that shifts often extend a bit longer than scheduled) should be reconsidered. The study supports previous findings of increased burnout among nurses who work shifts longer than eight hours, but finds as well that longer shifts (13 hours or more) are associated with increased levels of patient dissatisfaction.

Despite these negatives for both nurses and patients, 80% of nurses surveyed across four states said they were happy with their hospitals’ scheduling practices.

I imagine that, with all the recent emphasis on patient satisfaction scores, this study will make nurse executives and hospital administrators take notice—especially as consumers become more aware of the research through coverage like this story at the U.S News & World Report site.

We’ve had evidence for a while that the 12-hour shift is not a best practice. For example, in 2004, Anne Rogers and colleagues also published research in Health Affairs. In their national survey of over 1,000 nurses, they found that most nurses generally worked longer than their actual shifts; nearly 40% of shifts were longer than 12 hours, and 14% of respondents had worked “16 or more consecutive hours at least once during the four-week period.” More importantly, they found that “the likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting 12.5 hours or more.”

In 2006, Alison Trinkoff and colleagues published their research on the lengths of nursing shifts in AJN. Their conclusion: “The proportion of nurses who reported working schedules that exceed the recommendations of the Institute of Medicine should raise industry-wide concerns about fatigue and health risks to nurses as well as the safety of patients in their care.”

And just this May in AJN Reports, we examined the controversies surrounding 12-hour shifts, discussing the research and the issues involved.

In Nursing Outlook last January, American Academy of Nursing president Joanne Disch asked, “Are we evidence-based when we like the evidence?” It would seem so.

So the question remains: should nurses’ convenience trump patient safety and satisfaction, and our own health? Is it time to abandon the 12-hour shift?

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Diabetes Plus Marijuana Plus Medical Errors Minus Nursing Blogs

January 12, 2012

What’s new in health care news this week?

Diabetes everywhere. There’s an entire Health Affairs issue devoted to the topic of “Confronting the Growing Diabetes Crisis.” It looks at many interrelated issues, such as the personal financial burden of having diabetes over the course of a lifetime, whether it’s best to put scarce health care resources into focusing on prevention or treatment, models for community-based lifestyle programs for those with type 2 diabetes, the positive effects of the Affordable Care Act on giving those with diabetes access to affordable health insurance and crucial care, genetic factors related to type 2 diabetes, and a great deal more. Inevitably, many of the articles focus on type 2 diabetes, which is so closely linked to America’s obesity epidemic.

by Jorge Barrios, via Wikimedia

Joint studies. The New York Times reported this week on a large government study showing that, whatever one believes about marijuana’s psychological effects or the efficacy of its various medical uses, long-term marijuana smoking—at least one joint per day, every day of the year—does not impair lung function or contribute to the development of COPD. Will this change anyone’s mind about whether this drug is evil, a panacea for all ills, or somewhere in between? Probably not.

Unreported harm. The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services issued a report last week stating that only 14% of medical errors and other events that harm Medicare patients were reported by hospital employees. The report calls for improving reporting systems and the creation of a list of “potentially reportable events.” According to the New York Times story on the topic, adverse events that have gone unreported include “medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.”

Which leads us (or does it?) into nursing blogs. Many of the ones in our blogroll have been pretty silent in the past few months, or longer, and it’s not clear why. Some bloggers are taking a break, some have burned out or decided to use their time for other things (like going back to school), some have simply decided to spend more time on Facebook or sharing their thoughts by ‘microblogging’ on Twitter (or are simply playing lots of Words With Friends on their smartphones). There are almost certainly many interesting new nursing blogs we don’t yet know about that are taking their places. If you know about them, please let us know. We need to take some time and do some digging. And we plan on doing a serious revision of the blogroll in the next few weeks.—JM, senior editor  

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